A practice in the Hounslow area

10. Mr H complains that the Centre should have referred his son, Mr L, to hospital as an emergency patient in March 2023 to investigate his continuous bowel issues.

11. On 21 June 2023 Mr L had a private scan that showed he had bowel and colon cancer. He was admitted to hospital and sadly died on 25 June 2023.

12. Mr H says because his son was not given a referral to hospital, this delayed his cancer diagnosis and limited his treatment options. He feels the Centre did not give his son the best chance of survival and this led to his premature death which has been very distressing for him.

13. Mr H would like the Centre to make service improvements to ensure this does not happen to any other patients. He also seeks a financial remedy.

14. Mr L had ulcerative colitis (an inflammatory bowel disease). He had not had a flare up since 2011.

15. In January 2023 he had what he believed was a colitis flare up. The Centre provided him prednisolone (a steroid medication used to reduce inflammation) over the phone. The prescription was repeated for a few months without any discussions about its effectiveness.

16. Mr L attended the Centre for a face-to-face appointment and blood test on 6 March 2023. He was reporting worsening symptoms including increasing pain and rectal bleeding despite taking high levels of steroids. At this time the results of the blood test were not a cause for concern.

17. Mr L continued to feel unwell. He had another appointment at the Centre on 11 May 2023. He told it that he was having bowel movements up to 20 times a day.

18. On 21 June 2023 Mr L had a private scan that showed he had bowel and colon cancer. He was admitted to hospital and sadly died on 25 June 2023.

21. Mr H complains that in March 2023, the Centre did not refer his son for more tests when he told it he felt unwell, and his symptoms were getting worse. He says had it referred his son he would have been diagnosed with bowel and colon cancer sooner.

22. We recognise this has caused Mr H significant worry and upset and appreciate this will be particularly distressing, as his son died suddenly following his diagnosis of cancer in June 2023.

23. Mr L’s medical records show on 2 March 2023, he told the Centre he had worsening colitis symptoms, had begun having abdominal spasms, and had increased diarrhoea and rectal bleeding. He continued to request high doses of the steroid prednisolone.

24. The records also show Mr L had a blood test on 6 March 2023. The results were within normal range. The Centre continued to prescribe prednisolone.

25. The suspected cancer guidance outlines when patients should be referred under the two-week cancer referral pathway. It says that patients who are under 50, with rectal bleeding should be referred if their symptoms are ‘unexplained’. As Mr L had a diagnosis of ulcerative colitis, his symptoms were not assumed to be ‘unexplained’.

26. The BNF guidance says an emergency hospital admission should be arranged when an acute severe flare up of colitis is suspected. The colitis management guidance gives parameters for a diagnosis of acute severe ulcerative colitis. It says more than 6-8 stools a day, with visible blood in the stools, along with at least one other ‘feature of systemic upset’ indicate a severe colitis flare up. The guidance lists ‘features of systemic upset’ as a high heart rate, a fever, anaemia, or a high erythrocyte sedimentation rate (ESR – a test to detect inflammation in the body).

27. We can see from the medical records that Mr L had already reported 8 to ten bowel movements a day on 4 January 2023. On 2 March 2023 Mr L then reported that his general symptoms were worsening, he was still having diarrhoea, visible blood in his stool, and abdominal spasms. The records do not state how many bowel movements he was having, but as his symptoms are noted to be worsening, we can conclude that it is likely that he was having more than the 8 to ten reported in January.

28. Our GP adviser explained that the symptoms that Mr L reported to the Centre on 2 March 2023 were generally much worse than those he had in January. The records show he was still taking large amounts of steroids, had been for a sustained period, and his symptoms were continuing to get worse.

29. The colitis management guidance explains that patients should be treated with a ‘time limited course of oral corticosteroid’, such as prednisolone that Mr L was taking, for 4 to 8 weeks before further treatment should be considered.

30. Mr L had been taking prednisolone since 4 January 2023 meaning that by 2 March 2023, he had been taking prednisolone for over 8 weeks, and his symptoms were continuing to worsen. The Centre continued to prescribe Mr L prednisolone until 16 June 2023 without offering him further investigations or an admission to hospital as a severe ulcerative colitis patient. This is a period of 19 weeks.

31. It is not clear from the records whether Mr L was suffering from one ‘feature of systemic upset’ as outlined in the colitis management guidance, as his temperature and ESR were not recorded. Despite this, our GP adviser said the symptoms that Mr L was experiencing on 2 March 2023, and the fact that his symptoms were continuing to get worse even though he was consistently taking large amounts of steroids for more than 8 weeks, is an indicator of severe ulcerative colitis.

32. In line with the BNF guidance, severe and worsening cases of ulcerative colitis, such as the one Mr L was suspected to be suffering with, warrant an emergency hospital admission. Our GP adviser said at this stage, given that he was presenting with blood in his stools, an increasing daily amount of bowel movements, and abdominal spasms that were not being controlled with the long-term use of steroids, the Centre should have referred Mr L to hospital on 2 March 2023.

33. Our view is that in line with the BNF guidance, due to his worsening symptoms, the Centre should have arranged for Mr L to be admitted as an emergency to hospital on 2 March 2023. It did not, and we consider this to be a failing.

Impact

34. Mr H feels had the Centre referred Mr L sooner, he may have had access to treatments that could have either saved, or prolonged, his life.

35. Mr L attended the Centre for a face-to-face appointment and blood test on 2 March 2023. He was reporting worsening symptoms including increasing pain and rectal bleeding despite taking high levels of steroids.

36. He continued requesting repeat steroid prescriptions before another appointment with the Centre on 11 May 2023. At this appointment he told the Centre he was having up to 20 bowel movements a day with lots of blood and pain.

37. Following this Mr L continued requesting prescriptions of strong doses of prednisolone. He was provided with these by the Centre. On 21 June 2023 Mr L had a private CT scan to investigate his symptoms. Mr H explained that his son was worried about his symptoms and wanted them investigated further.

38. The 21 June 2023 scan showed that Mr L had a large malignant (cancerous) tumour in his bowel. He was admitted to hospital for treatment on the same day and had a flexible sigmoidoscopy to allow for biopsies of the tumour to be taken.

39. Mr L’s records show that on 22 June 2023 he was advised that he needed some level of surgical intervention to treat his cancer. The hospital explained to him that due to the size of his tumour, and the pressure that it was putting on his bowel, he was at risk of bowel perforation.

40. On 23 June 2023 the surgical treatment options were discussed with Mr L. A surgeon at the hospital explained to him that they would need to perform either a colectomy (surgery to remove part of his bowel), or install a stoma bag, to allow waste to bypass his bowel and leave the body through his stomach. They explained that the course of treatment would be dependent on what they found to be possible when they examined his abdomen during surgery.

41. On 24 June 2023 Mr L’s abdominal pain became suddenly and significantly worse and the records state that he had a ‘sense that something was very wrong’. The records explain that Mr L had begun calling his friends to say goodbye. The surgeons were concerned that the obstruction in his bowel was getting worse, and they decided to operate on Mr L immediately.

42. On the same day the surgeons attempted to perform surgery on Mr L. When they opened Mr L’s abdomen, they found that his bowel had perforated, meaning that they were unable to perform a colectomy. They also found that the extent of the cancer meant that his bowel was ‘stuck down’ and they were unable to bring any of it out to create a stoma. The surgeons thought the bowel perforation was the likely cause of Mr L’s sudden onset of pain.

43. The surgeons discussed the options and decided that Mr L no longer had any treatment options due to the bowel perforation and their inability to create a stoma due to the extent of his cancer.

44. It was explained to Mr L and his family that the decision was made to end the surgery, and to allow him to say goodbye to his family and friends rather than attempt a larger surgery that would not have been lifesaving, and would have meant that Mr L had to be intubated (a tube inserted to allow Mr L to breathe, with him being under anaesthetic) in the last few days of his life.

45. Following surgery Mr L was made comfortable with painkillers and was allowed to have family and friends visit to say goodbye. Mr L sadly died on 25 June 2023.

46. The IBD management guidance explains that adult patients who are admitted to hospital with severe ulcerative colitis symptoms, as Mr L should been, should have a diagnostic sigmoidoscopy (an imaging test to monitor activity in the colon) within 24 hours of admission.

47. The bowel cancer treatment guidance explains that the main test for bowel cancer is a colonoscopy or similar (such as a sigmoidoscopy). It explains that following this, you may need further diagnostic treatment such as a CT scan to access how far the cancer has spread.

48. Our oncology adviser explained that had the Centre sent Mr L to hospital as an emergency patient on 2 March 2023, in line with the IBD management guidance, the hospital would have arranged for him to have a flexible sigmoidoscopy to investigate his symptoms further. A sigmoidoscopy allows doctors to examine the colon for any abnormalities, including cancer.

49. Our oncology adviser said following this, in line with the bowel cancer treatment guidance he would have undergone a CT scan, and this would have confirmed his diagnosis of cancer. A multidisciplinary team meeting would then have taken place soon after to discuss the course of Mr L’s treatment.

50. Our oncology adviser said that when Mr L was diagnosed in June 2023 there was no obvious metastases (secondary cancerous growths at a distance from the primary cancer site). However, there were suspicions that the cancer may have started to grow into the lining of his abdomen. They explained that this means that in June Mr L’s cancer was already at an advanced stage.

51. Our oncology adviser explained given that Mr L’s cancer was already at an advanced stage in June 2023, it is likely he will have had cancer for some time prior to his June 2023 diagnosis. As such, our oncology advice said this means that even if he had been admitted to hospital in March 2023, he would have already had an advanced stage of cancer at that time.

52. Taking into account the advice we received and the relevant guidance, we consider that if the Centre had arranged for Mr L to have been admitted as an emergency on 2 March 2023, he would have undergone exploratory treatment and he would have been soon after diagnosed with advanced bowel cancer as was found on 24 June 2023.

53. The records show that Mr L experienced a bowel perforation on 24 June 2023. A bowel perforation is when a hole forms in the colon, causing the contents to leak into the abdominal cavity. It is a medical emergency, that can cause death if untreated.

54. Our oncology adviser explained that a bowel perforation is an acute medical emergency, meaning that it happens very quickly. They explained that it would not have been possible for Mr L to have already had this bowel perforation in March 2023.

55. On 12 May 2023 when Mr L had an appointment with the Centre, the records show that Mr L’s abdomen was examined, and it was ‘soft and non-tender on palpation’. Our oncology adviser explained that if Mr L had an obstruction to the extent that he did on 24 June 2023, his abdomen would not have been ‘soft’ or ‘non-tender’.

56. Although Mr L’s cancer would still have been advanced if he was admitted in March 2023, due to the evidence in the medical records of the appointment on 12 May 2023, we can conclude that he would not have had an obstruction to the extent that was found on 24 June 2023 in March 2023. Our oncology adviser therefore said that Mr L would have been able to have had a stoma fitted if the cancer had been diagnosed in March, as his obstruction would not have been to the extent it was in June 2023.

57. The guidance on recovery after stoma surgery explains that a stoma may be needed because of a growth in the large bowel, such as bowel cancer, or a bowel obstruction, where your bowel becomes so blocked that waste cannot pass through it. Mr L’s records show that he had a large cancerous growth in his bowel that meant that waste was no longer able to effectively pass through.

58. Our oncology adviser explained that installation of a stoma bag is the best course of treatment to avoid a bowel perforation and therefore would have avoided Mr L’s sudden bowel perforation and subsequent death at that time.

59. The guidance on recovery after stoma surgery explains that as with any operation, complications can happen during or after stoma surgery. It explains that with any patient, there is a small chance of infection around the stoma, or the stoma malfunctioning and causing a bowel blockage.

60. However, the guidance also says that after stoma surgery a patient will be monitored by a dedicated stoma nurse, meaning that any complications would be identified and treated promptly. As the risks of complications are minimal, we consider Mr L would have been able to receive treatment for his cancer following his surgery.

61. As previously explained Mr L’s cancer would have been extensive by this time, and there was suspicion that the cancer had spread to the lining of his stomach.

62. Our oncology adviser said this means that surgery to remove the cancer would not have been attempted as the cancer had spread so much that surgery would not be effective. The bowel cancer treatment guidance explains that when cancer begins to spread to other organs, such as in Mr L’s case the stomach, surgery to remove the cancer would be extremely difficult, and it would therefore likely not be attempted.

63. As surgery to remove the cancer was unlikely to have been attempted, our oncology adviser said that Mr L would have been offered palliative chemotherapy.

64. Mr L’s medical records show that he was actively seeking treatment for his bowel issues both with the Centre and at the hospital when he was admitted. It is recorded that Mr L asked on multiple occasions if anything could be done to treat his cancer. We can therefore conclude, on the balance of probabilities, that Mr L would have participated in any treatment that would have been offered to him if he was admitted and diagnosed in March 2023.

65. Our oncology adviser explained that following the stoma surgery Mr L would have had a period of recovery of around two months before he would have been ready to receive any palliative chemotherapy. The guidance on recovery after stoma surgery explains that it usually takes around eight weeks to recover from the surgery.

66. In line with this, at the latest, if Mr L had a stoma installed, he would have been ready to commence palliative chemotherapy by May 2023, following a period of surgical recovery.

67. The chemotherapy trial shows that palliative chemotherapy for patients with terminal colorectal cancer significantly increases life expectancy. The trial shows that in a random selection of patients with advanced colorectal cancer, which was determined to be ‘incurable’, palliative chemotherapy extended their life by on average 15 to 17 months versus patients with the same advanced colorectal cancer who had not received chemotherapy.

68. We can therefore conclude that had Mr L been admitted to hospital in March 2023 he would have had treatment which would have avoided the bowel perforation that he experienced on 24 June 2023. We also consider he would have been able to have palliative chemotherapy that would have extended his life.

69. We also need to consider the emotional impact that the delay in diagnosis will have had on Mr L and his family.

70. Mr L died four days after his cancer diagnosis. This was extremely distressing to him and his family, who did not have time to come to terms with this diagnosis.

71. If Mr L had been admitted to hospital in March 2023, and his cancer was discovered around this time, he would have received treatment that likely would have significantly extended his life.

72. He and his family would have had more time to come to terms with his diagnosis, and he would have had more of an opportunity to say goodbye to those closest to him. We have found that due to the Centre’s failings, this opportunity was taken away from him. This is an injustice which has not yet been put right.

1. Mr H told us his son, Mr L, developed bowel and colon cancer and very sadly died in June 2023. He has been left with serious concerns that the Centre missed an opportunity to refer his son for tests in March 2023 to investigate his symptoms sooner.

2. We can only imagine how traumatic and upsetting this time has been for Mr H. It must have been incredibly distressing to witness his son’s rapid decline in health. We recognise his long-lasting grief has also been made harder as he has concerns about the quality of his son’s care. We would like to thank him for taking the time to bring this complaint to us.

3. We have carefully considered all the evidence provided by the Centre and Mr H. We have found that the Centre should have referred Mr L to hospital as an emergency patient on 2 March 2023 to investigate his symptoms.

4. We consider this missed opportunity to refer Mr L to hospital in March 2023, caused an unnecessary delay in diagnosing his cancer. This meant that Mr L experienced a bowel perforation that likely would have been avoided.

5. Sadly, Mr L’s cancer had already progressed significantly by March 2023. We have found that even if he been diagnosed at this time, there would have been no curative treatment available. However, he lost the opportunity to have palliative chemotherapy that would have extended his life.

6. The lack of urgent action by the Centre and the decline in Mr L’s health would have been very upsetting for Mr H and the rest of the family to witness. Our decision will leave him feeling significant frustration and distress that more could have been done to support his son.

7. Further, we consider the delayed diagnosis, meant Mr L and Mr H had less time to emotionally prepare and come to terms with the diagnosis. This will also have caused significant emotional distress for Mr H.

8. We do not consider the Centre has done enough to put things right for Mr H. We uphold this complaint.

9. We have recommend the Centre produces an action plan to explain what service improvements it will make and provide Mr H with a financial remedy of £12,500.